ACO/MCO Continuity of Care FAQs February 2018

Transcription

1 ACO/MCO Cntinuity f Care FAQs February 2018 General Prgram Questins Starting March 1, 2018, new Accuntable Care Organizatin (ACO) and Managed Care Organizatin (MCO) cntracts will becme effective t imprve accuntability and integratin f care fr MassHealth members These changes apply t MassHealth managed care members (generally, this includes members under age 65 wh d nt have anther primary insurer, either cmmercial r Medicare, and are nt in a lng-term facility) 1. Hw d MassHealth s new ACO and MCO plans cmpare t current plans? Prir t March 1, 2018, there are tw types f plans these members may be enrlled in: Members enrlled in the PCC Plan receive care (including pharmacy) ther than behaviral health services frm MassHealth s fee fr service (FFS) netwrk. Claims fr these members are submitted t MassHealth accrding t MassHealth billing rules (including MassHealth s authrizatin requirements, MassHealth s frmulary, etc.) and are paid at MassHealth rates. Members enrlled in the PCC Plan receive behaviral health services frm MassHealth s behaviral health vendr, the Massachusetts Behaviral Health Partnership (MBHP). Claims fr behaviral health services fr members in the PCC Plan are submitted t MBHP accrding t MBHP s billing rules (including authrizatin requirements, etc.) and are paid at MBHP s negtiated rates. Members enrlled in ne f MassHealth s six MCOs receive MCO cvered services frm the cntracted netwrk f their MCO. Claims fr these members are submitted t the MCO (r their Pharmacy Benefit Manager (PBM) r, in sme cases, a behaviral health subcntractr) accrding t the MCO s billing rules (including authrizatin requirements, frmulary, etc.), and are paid at the MCO s negtiated rates. Starting March 1, 2018, members may enrll in any f the fllwing plan ptins, which fr many purpses are similar t the tw existing types described abve: MassHealth will still have a PCC Plan that will cntinue t perate as described abve. MassHealth will still have an MCO prgram, with tw MCOs (Bstn Medical Center Health Plan (BMCHP) and Tufts Health Public Plan (Tufts)) rather than six. In additin, MassHealth will have three Primary Care ACOs (Steward Health Chice, Cmmunity Care Cperative (C3), and Partners HealthCare Chice). Primary Care ACOs use MassHealth cntracted primary care, specialist and hspitals prviders. MBHP prvides behaviral health services, and Primary Care ACOs are respnsible fr ensuring that behaviral health services are integrated with physical health services fr members. Like members in the PCC Plan, claims fr nn-behaviral health services prvided t these members are submitted t MassHealth accrding t MassHealth administrative billing rules, and are paid at MassHealth rates. Claims fr behaviral health services fr are submitted t MBHP accrding t MBHP s administrative and billing rules, and are paid at MBHP s negtiated rates. MassHealth will als have 13 Accuntable Care Partnership Plans. Each Partnership Plan is jintly frmed by a prvider-led ACO and ne f five MCOs. Members enrlled in Partnership Plans receive care frm the cntracted netwrk f the MCO. Accuntable Care Partnership Plans are respnsible fr crdinating health care services, including integrating behaviral health and physical health. Like members in MCOs, claims fr these members are submitted t the Partnership Plan (r their PBM r BH vendr) accrding t the Partnership Plan s billing rules (including authrizatin requirements, frmulary, etc.), and are paid at the Partnership Plan s negtiated rates. Alng with Primary Care ACOs, Partnership Plans are ne f MassHealth s tw new ACO plan ptins. ACOs are grups f dctrs, hspitals, and ther health care prviders wh cme tgether t give crdinated, high-quality care t MassHealth members. This way, MassHealth members get the right care at the right time. When an ACO succeeds in bth delivering high-quality care and spending health care dllars wisely, MassHealth will reward the ACO. Please see Appendix D fr additinal detail n hw services and cntracting wrk under MassHealth s new plans

2 Member Questins 2. What shuld a member d if nt all f their prviders are in-netwrk in their ACO? Take the fllwing example: A member gets primary care frm a cmmunity health center that has jined a certain ACO. The member als receives specialty care frm several prviders. On March 1, 2018, this member has mst likely been special assigned t the ACO that their cmmunity health center has jined, t preserve their relatinship with their primary care prvider. This member may make a different plan selectin at any pint fr any reasn prir t June 1, 2018 This member s specialty prviders may r may nt all be in the ACO s new netwrk. The member shuld check the ACO s prvider directry, r call the ACO with any questins. If this member chses t remain in the ACO, but nt all f their prviders are in that ACO: This member may cntinue t see ut-f-netwrk prviders fr cntinuing care during the 30-day cntinuity f care perid If this member wants t cntinue t see ne f these prviders after the cntinuity f care perid rather than transitining t an in-netwrk prvider, this member shuld cntact their plan. The plan may add the prvider t their netwrk, enter int a single case agreement fr certain services, r help the member identify ther apprpriate specialists that are available in the netwrk. If the member is in a Primary Care ACO, the prvider will have t jin the MassHealth FFS netwrk in rder t cntinue seeing the member after the cntinuity f care perid ends. If this member wishes t leave their ACO and jin a different plan, in rder t maintain in-netwrk access t ne r mre f the member s specialty prviders: This member may cntinue t see their primary care prvider at their cmmunity health center during the cntinuity f care perid This member will have t chse a different PCP that is available in their new plan, and can call their new plan fr assistance making a selectin If this member receives ther services, such as Medicatin Assisted Treatment (MAT), frm their cmmunity health center, they may cntinue t see the cmmunity health center fr these services, even after the cntinuity perid, as lng as apprpriate netwrk arrangements are in place frm the member s new plan. 3. Hw d the cntinuity f care plicies ensure a smth transitin fr members with previusly scheduled appintments r prcedures in March? Members may cntinue t see their current prviders fr previusly scheduled appintments and nging treatments and services fr a minimum f 30 days frm their dates f enrllment, even if their prvider is nt part f the member s new plan netwrk. If prviders are nt part f the new plan s netwrk, they will need t make apprpriate arrangements with the Accuntable Care Partnership Plan, MCO, r MassHealth in rder t be paid by the new plan. 4. During the cntinuity f care perid, will prviders be paid fr services which nrmally d nt require a referral/authrizatin (e.g. a primary care visit) regardless f whether they were scheduled befre r after 3/1? Yes. 5. If a member received a letter assigning them t a new plan, r asking them t select a new plan, d they still have access t the 90-day Plan Selectin Perid t select a plan? Yes. Members will have the full 90-day plan selectin perid (beginning March 1 and ending May 31, 2018) t chse their health plan. Members received a packet in the fall which utlined the chices available t them in the gegraphy in which they lived. Shuld they have any questins abut the plans available in their area, they can call MassHealth Custmer Service at ; TTY: r visit MassHealthChices.cm.

3 6. What type f member utreach is being dne by MassHealth, Accuntable Care Partnerships and MCOs? When is it being dne/has it been dne? Last fall, fr members whse primary care prviders were jining ACOs, MassHealth made assignments fr ~800,000 members t these ACOs, t make it easier fr these members t keep their primary care relatinships. MassHealth sent ntices t all these members during Nvember and December infrming them f this assignment, listing the specific primary care prvider and the specific ACO, and encuraging the member t explre their plan ptins at MassHealthChices.cm and t call with any questins r cncerns. Nw, all ACO and MCO plans are sending members welcme packages that include member handbks, ID cards, and ther infrmatin abut the plan. This infrmatin has been r will be sent ut n r abut the member s date f enrllment. All member handbks and ther member educatin materials have been apprved by MassHealth. Materials include details such as plan benefits including cvered services, what requires PA/referrals, where t find infrmatin abut netwrk prviders, member rights and imprtant cntact infrmatin fr the plans. In additin, all ACO and MCO plans have had public-facing custmer service lines up and running since Nvember 2017 and have been engaging with members and prviders wh have questins. All plans have mechanisms fr cmmunicatin with members with regards t cntinuity f care: Several plans (but nt all) are planning t issue autmated ntices t members wh use ut-f-netwrk prviders r services that wuld nrmally require authrizatin during the cntinuity perid. These materials are als reviewed and apprved by MassHealth. Other plans have a mre targeted apprach, using a cmbinatin f claims mnitring and direct member utreach frm the plan s care manager r the member s primary care prvider t facilitate transitins t the plan s netwrk and authrizatin requirements Prvider Cntracting and Billing 7. Which prviders can be in-netwrk fr MassHealth s new ACO and MCO plans? All prvider types except fr primary care prviders may, as tday, participate in any ACO/MCO netwrks, as lng as they are able t reach cntracting terms with the plan. Any such prviders that wish t jin a netwrk may: Engage in cntract discussin with the MCOs fr participatin in their MCO and/r Partnership Plan prducts, and/ r Enrll with MassHealth fr participatin in MassHealth s FFS netwrk, which is available t Members in the in the PCC Plan and the three Primary Care ACOs, and/r Cntract with a plan s behaviral health netwrk r behavir vendr s netwrk (i.e. Tufts, Beacn and MBHP), assuming they are able t reach mutually acceptable cntracting terms Each primary care prvider that participates in an ACO may nly be in-netwrk fr that specific ACO fr the purpses f rutine primary care. This means that MassHealth members enrlled in ther plans will nt be able t select that prvider as their PCP fr rutine primary care services Yu may have heard this cncept referred t as primary care exclusivity T the extent these prviders serve members in a capacity ther than acting as the member s primary care prvider, they may still d s regardless f what plan the member is in, s lng as the prvider has the apprpriate cntracts and authrizatins in place with the member s plan. Fr example, if the prvider is cntracted with the member s plan they may cntinue t prvide services such as: Medicatin assisted treatment (MAT) Behaviral health services Outpatient services r ffice visits prvided in a specialty capacity Cverage services fr affiliated practices 3

4 Further, primary care exclusivity is enfrced at the site level. As is the case tday, individual clinicians may have relatinships with tw r mre sites f care where they practice (e.g., n different days f the week), and these sites may r may nt all be in the same ACO; these arrangements cntinue t be permitted withut changes Primary care exclusivity des nt impact members in the Special Kids Special Care Prgram 8. Hw will plans arrange fr payment during the cntinuity f care perid fr ut f netwrk prviders, and what shuld a prvider d if they wish t jin the netwrk f an ACO? Each Managed Care and Accuntable Care Partnership Plan has an apprach t cmpensating ut f netwrk prviders during this perid, and prviders shuld utreach t the plan directly t understand their apprach. In many cases, plans may put in place single case agreements with prviders. If a prvider wishes t jin the netwrk f the ACO r MCO n a permanent basis, the prvider shuld reach ut t the plan directly t arrange fr inclusin and payment, in essentially the same way they wuld with an MCO in tday s market. Fr the PCC Plan and Primary Care ACOs, under federal rules, MassHealth is nt allwed t make single case agreements fr these plans under its regulatry authrity. Instead, ut-f-netwrk prviders shuld seek t enrll with MassHealth as a prvider (and becme credentialed by MassHealth) and, nce enrlled, will be paid accrding t the MassHealth fee schedule. MassHealth has develped an expedited prcess fr prvider enrllment. Prviders interested in enrlling shuld call MassHealth custmer service at ; TTY: Fr members wh are aut-assigned, will there be any time befre they are frmally enrlled in their new plan? Almst all members have been assigned t their new plan with effective enrllment date n March 1 st. Certain members may be assigned t a new plan in in the first week f March, and thse members will be in MassHealth s FFS fr up t a week s time. Enrllments will nt be backdated t March 1. Prviders shuld bill the plan f recrd n the date f service (including MassHealth FFS, if applicable). New managed-care eligible members wh jin MassHealth after March 1, cnsistent with existing plicy, will remain in FFS fr a perid f up t 14 days. If these Members d nt select a plan ptin they will be assigned t a plan. Members 30-day cntinuity f care perids start n the day their enrllments are effective. 10. When shuld a prvider begin the prcess f arranging payment frm a member s new plan? Prviders shuld begin utreaching t a member's new plan as sn as they can verify it in MassHealth s Eligiblity Verificatin System (EVS), and shuld wrk with the plan f recrd n the date f service. 11. What if a prvider des nt wish t receive payment frm the member s new plan? MassHealth strngly encurages prviders t see members during the cntinuity f care perid and enter int payment arrangements with the member s new health plan. 12. Des the cncept f primary care exclusivity impact prviders and members during the cntinuity f care perid? N. Members may cntinue t see their prviders including their primary care prvider, and prviders shuld wrk with the member s current plan at the time f service (as displayed in EVS) t arrange payment. 13. Where can I find ut which plan a member is enrlled with? 4 Prviders can cnfirm enrllment in EVS.

5 Prir Authrizatins 14. Hw will authrizatins granted by the member s current plan that extend beynd 3/1 be handled by the member s new plan? During the cntinuity f care perid, all existing prir authrizatins fr services and fr prvider referrals will be hnred by the new plan. Members can cntinue t see all prviders currently prviding their care during this perid, even if that prvider is nt in their new plan s netwrk. Prviders shuld check members eligibility starting n 3/1 in EVS, and reach ut the members new plan t put g-frward authrizatins int place. 15. There has been sme discussin f transferring prir authrizatins frm ne ACO/MCO/PCC Plan t anther. Is that happening r shuld prviders be strictly pursuing getting all new prir authrizatins with the new plan? T the extent pssible, MassHealth, MBHP/ Beacn, and all MCOs have shared prir authrizatin infrmatin with new plans fr members wh are transitining. MassHealth and the new plans have been wrking t add knwn prir authrizatins int their systems t prepare fr new enrllees. Prviders shuld be cntacting the member s new plan f recrd after 3/1 (as displayed in EVS) where new authrizatins r renewals are required. If a prvider has any questin abut the status f a prir authrizatin, the prvider shuld cntact the plan. Behaviral Health 16. What is the cntinuity f care perid fr utpatient and nn-24 hur diversinary behaviral health services? 90 days. 17. If ur agency is currently cntracted with all existing MassHealthMassHealth behaviral health plans (MBHP, Tufts, and Beacn), will that cntract extend t the new plans? During the cntinuity f care perid, all existing prir authrizatins fr services and fr prvider referrals will be hnred by the new plan. In the vast majrity f cases (including the PCC Plan and Primary Care ACOs), behaviral health prvider cntracts with MBHP, Tufts and Beacn will extend t the new plans. Shuld yu have questins abut yur netwrk participatin, please cntact the plan directly. 18. Hw will members cntinue accessing MAT during the cntinuity f care perid and after? Members have the right t cntinue accessing MAT frm their current prescribers thrughut the cntinuity perid, with r withut a referral, regardless f the prescriber s netwrk relatinship with a plan Fr Accuntable Care Partnership Plans and MCOs: We expect all ur plans t make sure that all new enrllees are able t access a sufficient netwrk f MAT prescribers Plans are evaluating their MAT netwrks in advance f 3/1/18 t ensure they are as brad as pssible Fr members in the PCC Plan and Primary Care ACOs: MassHealth will credential and enrll any willing, qualified prvider f MAT services t ensure access fr members in these plans Fr prviders (including primary care): Regardless f which ACO mdel a prvider is assciated with, prviders may cntract with any plan r MassHealth fr the prvisin f MAT services. 5

6 19. Hw shuld MAT prviders bill fr MAT services prvided t a member whse PCP is in a different ACO frm the MAT prvider? MAT prviders (including PCPs, OBOT sites, etc.) may cntinue t cntract with any and all plans (including ACOs and MCOs) t prvide these services, including t members wh are nt assigned t them fr rutine primary care. MAT prviders shuld cntract with any plans whse members they wish t treat, and shuld bill these plans fr care prvided t these members as nrmal. 20. If a therapist is nt in-netwrk fr their client s new health plan, can they cntinue t bill the member s ld plan after March 1(as lng as there are still authrized sessins)? Prviders must bill the member s plan f recrd (as it appears in EVS) n the date f service (i.e., fr members enrlled in new ACO r MCO plans n 3/1/18, prviders shuld bill thse new plans fr any services rendered after that date). The new plan will hnr the authrized sessins fr services prvided during the duratin f the cntinuity f care perid r the duratin f the authrizatin, whichever cmes first. 21. Hw can a MassHealth member r a prvider identify which behaviral health plan the member is assigned t, if they cannt find the letter they were sent by MassHealth? The member shuld call MassHealth Custmer Service: ; TTY: , r a prvider can check EVS. When a prvider is lking up member eligibility and plan assignment in EVS, they shuld use the MassHealth ID 1000 number. Lng Term Services and Supprts 22. A previus payr has expired ur authrizatin as f 2/28/18 even thugh we have dcumentatin frm the physician fr 11 refills, and the authrizatin shuld have been extended beynd that date. What shuld the prvider d? The prvider shuld cntact the new plan t establish a new authrizatin. 23. Fr LTSS services paid fr directly by MassHealth and nt by the ACO/MCO, will MassHealth implement extensin prtcls if PCPs wn t sign PAs fr members they have nt seen/perhaps met? Mst members PCPs are nt changing because members were prspectively assigned t ACOs based n their existing PCP. Hwever, t the extent that a member s PCP des change (e.g., because the member selects a different plan), prviders and members shuld wrk with new plans and PCPs t get a new authrizatin and/r referral in place fr LTSS services that are paid fr directly by MassHealth. The new referral and authrizatin are nt needed until the existing authrizatin has expired. 24. Hw can LTSS prviders wh wrk with members receive authrizatin t speak t the plan n behalf f the member? There is n change t current plicy n a plan s cmmunicatins. The plan will wrk with the member r designated representative. 25. Can yu please clarify that if a patient is transferring frm the PCC plan t an Accuntable Care Partnership Plan r MCO (r vice versa), will we need t reapply t the new plan fr a new prir authrizatin during r after the 30 day perid? If a prir authrizatin is already in place fr the 30 day cntinuity f care perid, it will be hnred by the member's new plan (whether they are mving frm an ACO/MCO t the PCC plan r vice versa). The member and/r prvider shuld wrk with the member's new plan t arrange fr authrizatins beynd the 30 day cntinuity f care perid. 6

7 26. Are Adult Fster Care prviders and ther LTSS prviders that are currently paid directly by MassHealth (nt by MCOs) affected by ACOs? N, Adult Fster Care, Grup Adult Fster Care, Persnal Care Attendant, Adult Day Health, and Day Habilitatin cntinue t be paid directly by MassHealth. 27. Hw will prviders knw if 30 days is the end date f the authrizatin? Prviders shuld cntact the member s new plan t cnfirm current authrizatin status. Hwever, as a general rule, during the cntinuity f care perid, authrizatins frm prir plans will be hnred until the expiratin f the authrizatin r 30 days, whichever cmes first. Pharmacy 28. Hw will pharmacy claims be prcessed starting March 1, 2018? Cnsistent with current practice, pharmacies will be paid by a member s plan, subject t its rules, frmulary, and rates: If the member is in the PCC Plan r a Primary Care ACO, the pharmacy will be paid by MassHealth, accrding t the current MassHealth rate methdlgy. Pharmacies shuld submit claims t POPS the same way they already d. If the member is in an MCO r a Accuntable Care Partnership Plan, the pharmacy will be paid by the apprpriate MCO (r its PBM). Rates are based n cntracts between the MCO/Partnership Plan and pharmacies. As is currently the case, MCOs (and Partnership Plans) maintain their wn frmularies, and may have minr frmulary differences frm each ther and frm the MassHealth Drug List. 29. Hw will pharmacy netwrks change starting March 1? Fr members in the PCC Plan and Primary Care ACOs, all pharmacies (bth retail and specialty) that are cntracted with MassHealth will be in-netwrk. Fr members in Accuntable Care Partnership Plans and MCOs, pharmacies must be cntracted with the apprpriate MCO in rder t be in-netwrk. Pharmacies wh are cntracted with MCOs shuld cnfirm directly with these MCOs (1) that thse cntracts extend past March 1, 2018; and (2) if the MCO will ffer multiple ACO and/r MCO prducts as f March 1, 2018, which prducts the cntract applies t. 30. What if a member switches t a new plan that des nt cntract with their current pharmacy prvider? T ensure that members transitin t their new plans successfully and cntinue t have access t all the services they need, all members enrlling int a new plan n r after March 1, 2018, will have a minimum 30-day cntinuity f care perid. The cntinuity f care perid begins n the first day the member is enrlled with the plan. During this perid, members may cntinue t be served by their previus prviders (including specialty pharmacies), even if that prvider is nt part f the member s new plan netwrk. If prviders are nt part f the new plan s netwrk, they will need t make apprpriate arrangements with the Accuntable Care Partnership Plan, MCO, r MassHealth in rder t be paid by the new plan after the cntinuity f care perid. Fr any ther questins regarding pharmacy netwrks (including specialty pharmacies), call the Plan and PBM phne numbers listed in Appendix A. 31. Will c-pays change after March 1, 2018 due t the new ACO and MCO cntracts? 7

8 N. Pharmacy c-pays fr all MassHealth ACO and MCO members will nt change due t the new ACO and MCO cntracts. 32. What changes in member enrllment can I expect n March 1, 2018? A significant number f members will shift t a different plan, since members will mve t whichever ACO plan his r her primary care prvider participates in. Members have the ptin t switch plans freely fr the first 90 days f their enrllment. Members wh are enrlled in the PCC Plan can switch int an ACO r MCO at any time. Members wh change plans n March 1, 2018 may als experience a change in their PBM. (Please see the Appendix A belw fr pharmacy cntact numbers, by plan). 33. Hw can pharmacies knw which plan a member is in after March 1? As is the case tday, pharmacies shuld identify the member s plan n the date f service, and shuld bill the apprpriate plan r PBM. After March 1 pharmacies can cntinue using members plan-specific enrllment cards t verify eligibility. Each ACO (including each Primary Care ACO as well as each individual Partnership Plan) and MCO will issue its wn unique card t its members, which members may bring with them t the pharmacy. BIN/PCN/grup number cmbinatins are prvided n these cards. 34. What if a MassHealth member des nt have his/her membership ID card available at the pharmacy? If the member des nt have the card available when requesting service at a pharmacy (r if the BIN/PCN/grup is unavailable fr any reasn), belw are three ways t cnfirm MassHealth eligibility and plan enrllment: a) A list f BIN/PCN/Grup number cmbinatins can be fund in this dcument in Appendix C b) Cnsult MassHealth s Eligibility Verificatin System (EVS) at c) Submit a claim t MassHealth s Pharmacy Online Prcessing System (POPS): If pharmacies are unsure which plan a MassHealth member is in, they may chse t bill POPS. If the member is enrlled in an MCO r ACO Partnership Plan, POPS will send infrmatin back in the denial message t help the pharmacy identify the crrect plan t bill. Once a member s ACO/MCO plan is identified, additinal required infrmatin (such as the member s plan-specific ID number) can be btained by calling the plan (see cntact infrmatin in Appendix A belw). 35. What if the member s new plan r PBM denies a pharmacy claim? Pharmacists shuld call the new plan s pharmacy help desk t address the issue. The cntact infrmatin fr all plans is listed belw in Appendix A. 36. Can a member switch plans if she r he is dissatisfied with the new plan r PBM? All MassHealth members may switch plans fr any reasn during the first 90 days f their enrllment. Members enrlled in the PCC Plan may switch t an ACO r MCO at any time. 37. If a member has an existing prir authrizatin and switches plans n March 1, will the new plan hnr the existing prir authrizatin? 8 Yes, the authrizatin will be hnred by the new plan fr at least the 30-day cntinuity f care perid r until the end date f the authrizatin, whichever is first. MassHealth and Partnership plans are making every effrt t ensure existing PAs are transferred t a member s new plan befre March 1, 2018.

9 Mre infrmatin abut cntinuity f care can be fund in Pharmacy Facts 111 at If a member s plan has nt yet authrized a prescriptin fill, pharmacists may submit emergency verride claims t ensure members d nt experience gaps in care. 38. Hw can I submit emergency verride claims? Fr members in the MassHealth PCC plan r a Primary Care ACO, pharmacies can submit claims with a value f 03 fr Level f Service (field 418). MassHealth will pay the pharmacy fr at least a 72-hur, nn-refillable supply f the drug. After the prescriptin is adjudicated, the pharmacy shuld remve the 03 frm the level f service field befre the next fill. The DUR unit at UMass must be cntacted during nrmal business hurs t btain PA fr additinal refills. DUR can be reached at Fr members in Partnership ACO plans and MCOs, pharmacies shuld fllw the specific directins listed belw in Appendix B in rder t submit emergency verride claims. 39. Hw lng can a pharmacy prvide an emergency supply using the emergency verride mechanism? All pharmacy prviders can prvide at least a 72 hur emergency supply f a prescribed drug. All ACO/MCOs and MassHealth will prvide payment fr these emergency prescribed drugs. 40. If a prescriptin has n remaining refills and the riginal prescriber is nt in the member s new plan, will a new prescriptin frm that prescriber be hnred? Yes, the new prescriptin will be hnred. 41. If a member s previus plan restricted the member t using nly ne pharmacy under a cntrlled substances management prgram (CSMP), des this restrictin carry ver after March 1? What if that pharmacy is nt in the new netwrk? MCOs and Partnership ACO plans will be ntified f new members wh are currently enrlled in a CSMP at MassHealth r their previus MCO. The new plan will evaluate the member s case and make a determinatin abut future CSMP participatin. 42. If a member cannt get an appintment with a physician t btain a new prescriptin r prir authrizatin within 30 days, what shuld the member d? Members, as well as the pharmacy, shuld cntact the prvider t get a new prescriptin n file as sn as pssible. If a prir authrizatin is needed, members and pharmacies shuld wrk with the prvider t ensure the necessary dcumentatin is submitted t the new plan. Pharmacies shuld issue emergency verrides t ensure that apprpriate cntinuity f care is prvided while the authrizatin is in prcess. 43. Fr drugs where prir authrizatin has been granted fr multiple mnths but where the member must make a mnthly ffice visit fr each 30-day refill (e.g., narctics), what shuld the member d if the prescriber is nt in the member s new plan? If the prescriber is nt in the new plan, members (and their prviders) shuld cntact their new plan t make apprpriate arrangements. During the 30-day cntinuity f care perid, the member can see their existing prvider, even if the prvider is nt in the new plan s netwrk. If the member will cntinue t need a new prescriptin every 30 days fr the medicatin, a new prir authrizatin may be required by the plan. Prviders, members, and pharmacies shuld wrk tgether t ensure the new plan has all f the necessary infrmatin What shuld I d if a member s PBM isn t respnsive in addressing an issue?

10 Call the member s ACO r MCO plan at the phne numbers listed belw in Appendix A. 45. What shuld I d if a member s ACO r MCO plan isn t respnsive in addressing an issue? Call MassHealth s Custmer Service Center at r (TTY). 46. Will medical supplies currently billed under the MassHealth pharmacy benefit (e.g., diabetic test strips) cntinue t be cvered under the pharmacy benefit by all MassHealth ACOs and MCOs? All medical supplies currently cvered under MassHealth s pharmacy benefit will cntinue t be available thrugh a member s MCO r ACO plans pharmacy benefit. Pharmacists shuld direct questins regarding billing and dispensing prcedures t the member s MCO r ACO plan. 47. Hw is MassHealth changing its 340B plicy effective March 1, 2018? Starting March 1, 2018, ACO Partnership Plans and MCOs will n lnger be permitted t pay Cmmunity Health Centers (CHCs) fr drugs purchased thrugh the 340B prgram. CHCs are defined by MassHealth as health centers that are nt hspital licensed health centers. ACO Partnership Plans and MCOs may cntinue t pay hspitals and hspital licensed health centers fr drugs purchased thrugh the 340B prgram. ACO Partnership Plans and MCOs must cntinue t identify all 340B claims when reprting encunters t MassHealth using Submissin Clarificatin Cde 20. The PCC Plan and Primary Care ACOs will cntinue t pay all 340B cvered entities (including eligible CHCs) fr drugs purchased thrugh the 340B prgram, cnsistent with current plicy. Billing practices d nt need t change fr these members. 10

11 Appendix A: Custmer Service and Pharmacy Help Desk Cntact Inf fr all Plans Accuntable Care Partnership Plans ACO Custmer Service Pharmacy Help Desk Be Healthy Partnership (HNE) (Optum Rx) Berkshire Falln Health Cllabrative BMC HealthNet Plan Cmmunity Alliance BMC HealthNet Plan Mercy Alliance BMC HealthNet Plan Signature Alliance BMC HealthNet Plan Suthcast Alliance (Eligibility Verificatin) (CVS Caremark) (chse pharmacy ptin in call menu t reach Envisin, BMC s PBM) (chse pharmacy ptin in call menu t reach Envisin, BMC s PBM) (chse pharmacy ptin in call menu t reach Envisin, BMC s PBM) (chse pharmacy ptin in call menu t reach Envisin, BMC s PBM) Falln 365 Care (Eligibility Verificatin) (CVS Caremark) My Care Family (NHP) (CVS Caremark) Tufts Health Tgether with Atrius Health Tufts Health Tgether with BIDCO Tufts Health Tgether with Bstn (CVS Caremark) (CVS Caremark) (CVS Caremark) 11

12 Children s ACO Tufts Health Tgether with CHA (CVS Caremark) Wellfrce Care Plan (Falln) (Eligibility Verificatin) (CVS Caremark) Primary Care ACOs ACO Custmer Service Pharmacy Help Desk Cmmunity Care Cperative (C3) (Cnduent) Partners HealthCare Chice (Cnduent) Steward Health Chice (Cnduent) MCOs ACO Custmer Service Pharmacy Help Desk BMC HealthNet Plan (chse pharmacy ptin in call menu t reach Envisin, BMC s PBM) Tufts Health Tgether (CVS Caremark) PCC Plan ACO Custmer Service Pharmacy Help Desk Primary Care Clinician (PCC) Plan (Cnduent) 12

13 Appendix B: Emergency Override Cdes fr Plans Accuntable Care Partnership Plans Be Healthy Partnership (HNE) Berkshire Falln Health Cllabrative BMC HealthNet Plan Cmmunity Alliance BMC HealthNet Plan Mercy Alliance BMC HealthNet Plan Signature Alliance BMC HealthNet Plan Suthcast Alliance Falln 365 Care Emergency Override Cde Call (Optum Rx) fr verride Value f 03 in field 418 (level f service) Overrides by phne call nly: Overrides by phne call nly: Overrides by phne call nly: Overrides by phne call nly: Value f 03 in field 418 (level f service) My Care Family (NHP) Tufts Health Tgether with Atrius Health Tufts Health Tgether with BIDCO Tufts Health Tgether with Bstn Children s ACO Tufts Health Tgether with CHA Wellfrce Care Plan (Falln) Primary Care ACOs Cmmunity Care Cperative (C3) Partners HealthCare Chice Steward Health Chice Value f 03 in field 418 (level f service) Emergency Override Cde Value f 03 in field 418 (level f service) Value f 03 in field 418 (level f service) Value f 03 in field 418 (level f service) MCOs BMC HealthNet Plan Overrides by phne call nly: Tufts Health Tgether

14 PCC Plan Primary Care Clinician (PCC) Plan Emergency Override Cde Value f 03 in field 418 (level f service) 14

15 Appendix C: BIN/PCN/Grup Numbers fr ACOs, MCOs and PCC Plan Accuntable Care Partnership Plans MCO Partner PBM BIN PCN Grup Be Healthy Partnership (HNE) HNE OptumRX MHP HNEMH Berkshire Falln Health Cllabrative BMC HealthNet Plan Cmmunity Alliance BMC HealthNet Plan Mercy Alliance BMC HealthNet Plan Signature Alliance BMC HealthNet Plan Suthcast Alliance Falln CVS Caremark ADV RX6429 BMCHP Envisin BCAID MAHLTH BMCHP Envisin BCAID MAHLTH BMCHP Envisin BCAID MAHLTH BMCHP Envisin BCAID MAHLTH Falln 365 Care Falln CVS Caremark ADV RX6430 My Care Family (NHP) NHP CVS Caremark ADV RX1653 Tufts Health Tgether with Atrius Health Tufts CVS Caremark ADV RX1143 Tufts Health Tgether with BIDCO Tufts CVS Caremark ADV RX1143 Tufts Health Tgether with Bstn Children s ACO Tufts CVS Caremark ADV RX1143 Tufts Health Tgether with CHA Tufts CVS Caremark ADV RX1143 Wellfrce Care Plan (Falln) Falln CVS Caremark ADV RX6431 Primary Care ACOs MCO Partner PBM BIN PCN Grup Cmmunity Care Cperative (C3) MassHealth Cnduent Partners HealthCare Chice MassHealth Cnduent Steward Health Chice MassHealth Cnduent MASSPRO D MASSPRO D MASSPRO D MassHealth MassHealth MassHealth MCOs* MCO PBM BIN PCN Grup 15

16 Partner BMC HealthNet Plan BMCHP Envisin BCAID MAHLTH Tufts Health Tgether Tufts Caremark ADV RX1143 PCC Plan MCO Partner PBM BIN PCN Grup Primary Care Clinician (PCC) Plan MassHealth Cnduent MASSPRO D MassHealth *Members f the Lahey Clinical Perfrmance Netwrk ACO shuld submit claims t the apprpriate MCO using the infrmatin abve. 16

17 Appendix D

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